State Employees' Deferred Compensation Plan Change Form

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P.O. Box 19208, Springfield, IL 62794-9208

STATE EMPLOYEES' DEFERRED COMPENSATION PLAN

CHANGE FORM

Please type or print clearly in ink. Initial any corrections, additions, deletions or changes in pen. Fill out your name, social security number and payroll

code number; complete additional information only if it reflects a change. For more information, call the Deferred Compensation Office at 1-800/442-1300,

1-217/782-7006 or TDD 1-800/526-0844.

Last Name

First

Middle Initial

Social Security Number

Street

City/State

Zip Code

Date of Birth

Agency or University

Office Phone Number

ome Phone Number

(

)

(

)

Work Address

Payroll Code No.

______________________

(See your pay stub)

SECTION A: TRANSACTION TYPE

Check Appropriate Box(es).

Change in Deferral Amount

Change of Mailing Address

Name Change (State Previous Below)

(Complete Section B)

(Home)

Revocation

Change of Work Address

Transfer to New Agency

(Complete Section C)

(Effective Date)

SECTION B: AMOUNT OF DEFERRAL

- The minimum amount of deferral is $10 per pay period or $20 per month, whichever is greater. Indicate

the amount to be deducted from each paycheck. Deferral changes can be effective no sooner than the first pay period of the next month.

I hereby elect to participate in the State Employees' Deferred Compensation Plan. I authorize the State of Illinois to defer from

my total compensation $__________ each pay period until my termination, modification or revocation of this amount, beginning

the

first or

second pay period in _______________________ .

(month)

(year)

SECTION C: REVOCATION OF DEFERRAL

I hereby revoke my election to participate in the State Employees' Deferred Compensation Plan, effective the pay period beginning

the

first or

second

pay period in _______________________.

(month)

(year)

READ THIS INFORMATION COMPLETELY BEFORE SIGNING

1. I am aware that the change in my deferral amount may be effective no sooner than the first pay period of the next month.

2. I am aware that my deferrals will continue to be invested as previously instructed, and that if I wish to make an investment

allocation change I may do so by calling the Plan's recordkeeper (T. Rowe Price) at 1-888-457-5770.

3. I am aware that my revocation may be effective immediately following approval by the Department.

4. I am aware that any Name, Address, or Agency change will be effective upon approval of this form.

Signature X

Date

Send this completed form to your Agency Liaison - or send directly to the Department of Central Management Services.

Liaison

Approval of Deferred Compensation Office required before

Name________________________________ Agency___________________________

any transaction takes place.

Date ________________________________ Phone No._________________________

Date

In compliance with the State and Federal Constitution, the Illinois Human Rights Act, the Americans with Disabilities Act and Section 504 of the Federal Rehabilitation Act, the Department of Central

Management Services does not discriminate in employment, contracts, or any other activity.

IL 401-1571

CMS-DC-274 (Rev. 03/07)